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If you are receiving this payment request prior to your dental appointment, the amount listed below is the amount due for your planned treatment. If you have dental insurance, the amount is your estimated Deductible, Copayment, and/or Coinsurance. If you are receiving this payment request after receiving treatment, the amount listed below represents remaining charges on your account (after insurance claims and payments have been received, if applicable).

Please call our office at (937) 226-1400 if you have any questions about these charges.

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Patient Name:

Date of Birth:

Important: Please manually enter your credit card information. Due to heightened security measures, auto-filled credit card information will likely be rejected.

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